• Doctor
  • GP practice

Elm Lodge Surgery

Overall: Good read more about inspection ratings

2 Burbage Road, London, SE24 9HJ (020) 7274 6138

Provided and run by:
Elm Lodge Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Elm Lodge Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Elm Lodge Surgery, you can give feedback on this service.

29 June 2019

During an annual regulatory review

We reviewed the information available to us about Elm Lodge Surgery on 29 June 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

10 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Elm Lodge Surgery on 10 May & 7 June 2016. The practice was rated good overall and requires improvement for key question: Are services safe? The full comprehensive report from this inspection can be found by selecting the ‘all reports’ link for Elm Lodge Surgery on our website at www.cqc.org.uk.

This inspection was an announced desk-based review carried out on 10 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 10 May & 7 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At our previous inspection undertaken on 10 May & 7 June 2016, we rated the practice as requires improvement for providing safe services as:

  • The practice had not taken the necessary action to mitigate risks associated with infection control.

  • The practice did not have a supply of chlorphenamine (used to treat allergic reactions) and hydrocortisone for injection (used to treat swelling or inflammation) in their supply of emergency medicines in accordance with current legislation and guidance.

  • Not all equipment in the doctor’s emergency bags had been calibrated to ensure that it was functioning and safe to use.

  • Not all staff had received essential training including safeguarding, basic life support training and infection control.

In addition to the breaches in regulation we found areas where we suggested the practice should make improvement. For example:

  • The practice had identified a lower number of patients with chronic obstructive pulmonary disease compared to rates of identification in other practices locally and nationally.

  • The practice’s system of recruitment checks was not sufficiently comprehensive.

  • One member of staff was not chaperoning in accordance with current guidance.

The practice is now rated as good for the key question: Are services safe?

Our key findings were as follows:

  • The practice had taken actions to ensure that risks associated with infection control had been addressed.

  • The practice had a supply of emergency medicines which reflected current guidelines.

  • All staff had completed essential training in accordance with current recommendations and guidance.

  • All clinical equipment had been calibrated.

    We also saw evidence the practice had:

  • Undertaken comprehensive recruitment checks for their most recently recruited member of staff.

  • Sent a reminder to staff regarding chaperone procedures within the practice.

  • Not taken action to increase the identification of patients with Chronic Obstructive Pulmonary Disease. However, the practice had reviewed their performance and attributed lower prevalence to being located in an area of low pollution and as a result of having a lower proportion of smokers on their patient list.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

10 May 2016 & 7 June 2016

During a routine inspection

We carried out an announced comprehensive inspection at Elm Lodge Surgery on 10 May 2016. Due to unforeseen circumstances, not related to the practice, we undertook a second visit on 7 June 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients relating to infection control, supply of emergency medicines and recruitment of staff were not consistently well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. Though some staff were missing some mandatory training.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Most patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • With the exception of the practice’s stock of emergency medicines the practice had good facilities and was well equipped to treat patients and meet their needs; though we also found that equipment in doctor’s bags had not been calibrated.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients and we saw evidence that they would act on this where practicable.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure that arrangements are in place to identify and mitigate infection control risks.
  • Ensure that the practice has a stock of emergency medicines that reflect current guidelines.

  • Ensure that all staff complete mandatory training in accordance with current guidance including but not limited to safeguarding, basic life support training and infection control.

  • Ensure that all clinical equipment is regularly calibrated.

The areas where the provider should make improvement are:

  • Review the practice’s chaperoning policy and ensure that staff are chaperoning in accordance with current guidelines.

  • Review patients with a view to increasing identification of those with Chronic Obstructive Pulmonary Disease.

  • Ensure that appropriate pre-employment recruitment checks are completed for all staff.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice